Principles of Endodontics

II

Retreatment

Hossein Moosavi DDS,MDS

Diplomate of the American Board of Endodontics
11/27/2018
Success/Failure of RCT
posttreatment disease
 Reasons for
failure
There are many causes for “failure” of initial
endodontic therapy that have been described in the
endodontic literature . These include iatrogenic
procedural errors such as poor access cavity design,
untreated canals (both major and accessory), canals
that are poorly cleaned and obturated, complications of
instrumentation (ledges, perforations, or separated
instruments), and overextensions of root filling
materials. Coronal leakage has also been blamed for
posttreatment disease, as has persistent intracanal and
extracanal infection and radicular cysts.
Etiologic factors for
failure
• Persistent or reintroduced intraradicular
microorganisms
• Extraradicular infection
• Foreign body reaction
• True cysts
Persistent or reintroduced intraradicular
microorganisms
•When the root canal space and dentinal tubules are contaminated with
microorganisms or their byproducts, and if these pathogens are allowed
to contact the periradicular tissues, apical periodontitis ensues.
Inadequate cleaning, shaping, obturation, and final restoration of an
endodontically diseased tooth can lead to posttreatment disease.
 Extraradicular infection
Occasionally, bacterial cells can invade the
periradicular tissues either by direct spread of
infection from the root canal space via contaminated
periodontal pockets that communicate with the apical
area, extrusion of infected dentin chips, or by
contamination with overextended, infected
endodontic instruments.
Foreign body reaction
•Occasionally, persistent endodontic disease occurs in the absence of
discernable microorganisms and has been attributed to the presence of
foreign material in the periradicular area.
 True
cysts
Cysts form in the periradicular tissues when retained embryonic epithelium
begins to proliferate due to the presence of chronic inflammation. The
epithelial cell rests of Malassez are the source of the epithelium, and cyst
formation may be an attempt to help separate the inflammatory stimulus
from the surrounding bone. The incidence of periapical cysts has been
reported to be 15% to 42% of all periapical lesions, and determining
whether periapical radiolucency is a cyst or the more common periapical
granuloma cannot be done radiographically. There are two types of
periapical cysts: the periapical true cyst and the periapical pocket cyst. True
cysts have a contained cavity or lumen within a continuous epithelial
lining. With pocket cysts, the lumen is open to the root canal of the
affected tooth. True cysts, owing to their self- sustaining nature, probably
do not heal following nonsurgical endodontic therapy and usually require
surgical enucleation
Diagnosis of posttreatment disease
To make a correct diagnosis, clinicians must rule out
nonodontogenic etiology, perform all appropriate
tests, properly interpret the patient’s responses to
these tests, derive a definitive diagnosis, and decide
on treatment options.
Treatment planning
•The patient harboring true endodontic
posttreatment disease has four basic options for
treatment:
1. do nothing
2. Extract the tooth
3. Nonsurgical retreatment
4. Surgical retreatment
Diagnosis
Diagnosis
Diagnosis
Post removal
• These can be classified into two categories: prefabricated posts and
custom-cast posts. Historically, cast posts were more commonly
used than prefabricated posts, but over the past 2 decades, cast
posts have become much less popular.
• Prefabricated posts: The design of posts also can be sub-
classified into active (threaded), passive, vented, fluted , and
acid-etched groups. There are also many materials that have been
used to fabricate posts: stainless steel, gold, titanium, ceramic,
zirconium, and fiber-reinforced composite posts. Cast posts, which
are fabricated in a laboratory, will always be made up of precious or
non-precious metal alloys.
Post removal

Pathways of the pulp

Post Removal
Techniques

1) Ultrasonic tips
2) Post removal kits (Gonon kit, Ruddle kit,..)
3) Drilling through post (fiber posts, cast posts)
Post Removal
Techniques
Ultrasonic tips :
The use of ultrasonic energy for prolonged periods of
time can generate excessive amounts of heat. The
heat generated can cause damage to the surrounding
periodontium. This damage may be as serious as both
tooth and permanent bone loss.
Gutta-percha Removal
•One of the great advantages of using gutta-percha for root filling is its
relative ease of removal. When the canal contains gutta-percha and
sealer or a chloropercha filling, it is relatively easy to remove this
material using a combination of heat, solvents, and mechanical
instrumentation
 Gutta-percha Removal

Chloroform Halothane Rectified turpentine Xylenes

Eucalyptol
Managing Solid Core Obturators

Solid core canal obturation systems, such as Thermafil, densFil, and

the GT Obturator have become very popular since their introduction
several years ago. After cleaning and shaping procedures are
completed, the clinician heats a solid core obturator (alpha-phase
gutta-percha surrounding a core that is attached to a handle) in an
oven and places the carrier in the canal. The solid core carries the
gutta-percha down into the canal and condenses it while the material
is cooling. This system provides a rapid and simple technique for
warm gutta-percha endodontic obturation. As with any obturating
material, retreatment will be necessary occasionally.
 Paste Retreatment
Various pastes have been used as root canal obturating materials, especially
outside North America. There are such a wide variety of paste compounds used in
endodontics that it is impossible to categorize them all. The individual clinician
who is using it formulates most pastes, so the ultimate composition of a paste
found in a tooth with persistent disease is generally indiscernible. Many of the
pastes used, such as N2 or RC2B, contain formaldehyde and heavy metal oxides,
making them toxic and a potential danger to the patient’s health, both local and
systemic if overextended beyond the confines of the root canal system. None has
the potential to seal the canal effectively, and many render a tooth impossible to
retreat, so their use is strongly discouraged. On radiographic examination, they
can usually be discerned by their lack of radiopacity, the presence of voids, and
evidence of inadequate canal shaping and poor length control .
Silver Point Removal
Historically, the use of silver points for endodontic therapy has been extremely
popular and quite successful because of their ease of handling and placement,
ductility, radiopacity, and because silver appears to have some antibacterial
activity. However, over the past few decades, the usage of silver points has
dramatically diminished. Presently they are considered a deviation from the
standard of care. The main reason for this change is because they corrode over
time and the apical seal may be lost. Also, silver points do not produce an
acceptable three-dimensional seal of the canal system; rather, they simply
produce a plug in the apical constriction while not sealing the accessory canals
that are frequently present The corrosion of silver points occurs when they come
into contact with tissue fluids and certain chemicals used in endodontics,
including sodium hypochlorite and some sealers. This corrosion produces
chemicals such as silver sulfide, silver sulfate, silver carbonate, and silver amine
hydrate, which have been shown to be cytotoxic in tissue culture. Corrosion
occurs mainly at the apical and coronal portions of the points, indicating that
leakage is responsible.
Repair of perforations
Occasionally, posttreatment endodontic disease will
be the result of root perforation. Root perforations
are created pathologically by resorption and caries
and iatrogenically during root canal therapy (zip, strip,
and furcation perforations) or its aftermath (e.g., post
preparation perforation).
 Perforations

Pathways of the pulp

 Perforations

19 months follow up
Pathways of the pulp
Prognosis of retreatment
• When the proper diagnosis has been made and all of the technical
aspects of retreatment are carefully performed, orthograde retreatment
can be highly successful. The prognosis depends to a large extent on
whether apical periodontitis exists prior to retreatment. In a recent
systematic review of outcomes studies, investigators report that in the
absence of prior apical periodontitis, the incidence of healed cases after
both initial treatment and orthograde retreatment ranges from 92% to
98% up to 10 years after treatment. When prior apical periodontitis is
present, the incidence of healing drops to 74% to 86%, regardless of
whether initial treatment or orthograde retreatment was performed. The
authors state that this “similar potential to heal after initial treatment
and orthograde retreatment challenges the historic perception of the
latter having a poorer prognosis than the former.
 Nonsurgical Retreatment
Survival
• Salehrabi & Rothstein (2010) – 4744 Teeth (LOE – 4)
• Treatment by Endodontists (2000-2007)
• Delta Dental Insurance Data Center
• 5 Year Follow-up
• Survival - 89%
• 85% Required No Additional Endo Procedures
• 4% Required Apical Surgery
• Failures – 11% (Extracted)
J Endod 2010;36:790-792
EXAMPLES:
1) failure- missing canal
2) perforation – perfed tooth- he sealed It and pt came back 2 days later
when tried to place post- they perforated
forced to take tooth out bc perforated all the way to gum
3) these posts – large posts- when u choose your post size be careful!
too large- will fracrure
4) large post, missing anatomy, having pain, discomfrot
took post out, found extra canals, redid rct and pt is doing okay
5) too lazy to find canals- just put posts – NO - u woudlnt do that on family
6)Restorabiltiy? take post out- will u have enoguh tooth structure?
is it restorable?
7) missed MB2- pt had a lot of pain
had sensitivity to cold!!
tissue on MB2 was still there! so pt feels that
8) missing anatomy- 82 yo patient came a week ago
severe pain
big lesion
missed a canal!!
did scan didn’t do the MB!
if your looking for distal canal and found one, but u know for first molar u have MB and ML 100%
of time!!!
remove everythign put CaOH in tooth
then wait till assym and no pain no problem then we finsih it!
B has been there for years so want to make sure we clean everythign
9) general dentist changing crown but he didn’t like the RCT – did scan- missed MB2- no lesion though
pt asked If I really need rct retreatment – rct is short, missed canal, but its working… no lesion no
RL
its up to the pt- if they don’t want it- can monitor and check it every so often
missed mb2 and bad root canal
but they left it .. judgement call
if he finds crack inside– take tooth out, then pt says well its working for me for many years why
take it out
13) broken- can go back in and try to save it but need ot tell pt there is a chance the
restorative dentist need crown lengthing
pt will say did retreatment – then crown lengthenign then crown
sometiems pt says so much money couod have gotten implant
but sometimes it works pretty good – but need to let pt know all the facts
14) seperated instruement
darkness is thickening in sinus= infection in sinus
15) retreatment of tooth
large lesion and conserned about shape of resorption of tooth
silver
hx of breast canacer
lesion 1/2mm to IAN
and pt hasn’t gone to docotr in so long bc scared of what they will say
he says okay I will do retreat but I think u need to get a biopsy- she freaked out and left
they decided to take tooth out and sended to biopsy
retreat and then issues wouldn’t be good bc could be metastatic from breast cancer
16) seperated file, large post
we can try to save it but we need crown lengthening
took out post and seperated instruemnt, obturated
did crown lengthing
better
but there was a chance that I may need tot take out.. she gave it a try
I think it worked
17) seperated insturment
pus came out- cleaned it all
and reobtruated
but had to remove a lot of tooth strucutre to get to end of the tooth!